Planning and Preparedness for Children's Needs in Public Health Emergencies

This resource was developed by AHRQ as part of its Public Health Emergency Preparedness program, which was discontinued on June 30, 2011. Many of AHRQ's PHEP materials and activities will be supported by other Federal agencies. Notice of transfer to another agency will be posted on this site.

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Frequently Asked Questions and Answers

Question 1: Is there a psychological impact on children who are involved in drills such as having a SWAT team come into a school with guns, etc.?

Answer (Dr. Jeffrey Upperman): I am not a mental health specialist. As you know, I am a pediatric surgeon, so we just say "cut it out." The reality is there might be some impact, but most kids, when they see people running around with special uniforms and guns and the fire department come in, they actually think it is pretty cool. I think if you did the appropriate briefing and debriefing with the children and their parents, who may be in attendance at your drills, I think they will do okay. You really need to set up the day and make sure they get a holistic experience.

Answer (Dr. Sarita Chung): I agree with Dr. Upperman. Every drill that we undergo is with the involvement of our mental health team, psychiatry, social work, and child life specialists. The children involved in any drill at our institution have a pre-meeting drill with our mental health team to understand the purpose of the drill. During the drill, our mental health team is constantly assessing the children. If there is a child that is clearly overwhelmed by the drill, he/she is taken out immediately and his/her concerns are addressed.

Question 2: Can the presenters talk about the deployment of mental health professionals as part of their team response?

Answer (Dr. Jeffrey Upperman): We have psychologists and psychiatrists as part of our Pediatric Disaster and Resource Training Center in Los Angeles County and, in fact, we are working very closely with the Los Angeles Emergency Medical Services system in developing programs and demonstration projects to look at these professionals and how they are deployed. We also are working with faculty from the University of California, Los Angeles, in looking at mental health triage implements in our disaster exercises. So mental health is very much a part of our team, and they are involved in every aspect of our planning.

Answer (Dr. Sarita Chung): Once again, I agree with Dr. Upperman; our mental health team is a crucial part of any disaster response.

Question 3: What programs or suggestions would you use to train the community emergency department to be able to care for children?

Answer (Dr. Sarita Chung): The first thing you have to realize in community emergency rooms or in general emergency rooms, the ones where Dr. Boyer practices, is you really need to look at your inventory and make sure that you have adequate pediatric equipment. Children range in size from an infant to a teenager. At the bare minimum, you should make sure that you have equipment for all sizes in order to care for children of different sizes. Secondly, think about contacting your pediatrics staff if you feel there is not as much pediatric input so that they can give guidance on treatment and care. Lastly, think about a memorandum of understanding to your children's tertiary care sites so that you will have a direct place where you would send your children that require more specialized care.

Question 4: The National Association for School Nurses (NASN) has been involved in preparing school nurses in disaster preparedness planning and execution. To what extent have school nurses/NASN been involved in preparedness efforts?

Answer (Bill Modzeleski): Let me, first of all, give out thank yous to all of the school nurses that worked tirelessly over the last several weeks with the issues related to the flu. We work very closely, not only with the Association, but with a lot of the front-line nurses that struggled mightily through this event. I can say that testimony provided last week in the House Committee from Jack O'Connell, who is the State Superintendent of Schools in California, acknowledged the fact that there is a need for many, many more school nurses. One, is their need. Two, is that they are working tirelessly in the field, and thanks to them. We have worked closely with school nurses, and we are continuing to work with them. We clearly understand that we will not be successful or effective without the help and cooperation of the school nurses.

Question 5: What do you suggest in planning for displaced children and/or orphaned children during emergencies?

Answer (Bill Modzeleski): That is a great question. I want to go back to the fact that, when we talk about schools and planning for schools, we talk about community planning. This is not just about school planning. Schools can do their part about making sure that the schools are open and they are educated, but this is an issue where you need to work with local service providers and local officials to make sure they are taken care of. Schools have a part of it, but it is not the entire picture.

Question 6: Is it possible to access or get a copy of SurgeWorld, Dr Upperman's surge capacity video game, and other resources developed by PDRTC?

Answer (Dr. Jeffrey Upperman): The Pediatric Disaster Resource and Training Center has a whole host of implements, and, actually, Dr. Chung came and joined us during our family reunification workshop that we had back in the spring. All of those are available at www.chladisastercenter.org. What I am told by our gaming people is that the final version will be up shortly. We have just been doing the beta testing, and it is looking great.

Question 7: Although schools often have crisis plans, once written, these usually are only monitored annually, nor are practice drills consistently conducted. Any suggestions for school nurses who know the importance of these last two items?

Answer (Dr. Sarita Chung): I think one of the important roles school nurses can play is to be a strong advocate for disaster preparedness—to use their knowledge of the schools' populations and ensure the crisis plans are practical and executable. Advocating for more drills with involvement of local response teams would also be helpful.

Question 8: Funding to schools for emergency planning has been mentioned by the speakers. Is there a specific grant for schools to apply for to receive these funds?

Answer (Bill Modzeleski): Yes, there is. It is actually known as REMS, Readiness Emergency Management for Schools. The good news is that we are going to make grant awards in fiscal year 2009 totaling about $35 million dollars. The other good news is that starting in fiscal year 2008, we also made awards to institutions of higher education. For these institutions, it is lesser money, but they are both available. In fiscal year 2010, it is in the President's budget, so we assume that opportunity will be available again. It is closed for fiscal year 2009 but will reopen again in 2010.

Question 9: Dr. Chung, regarding your recommendation for student medications to be transported in evacuation and relocation, do you recommend taking all medications or only emergency medications? Also, is it necessary to try to gather all the ADD/ADHD medications?

Answer (Dr. Sarita Chung): I think, ideally, you would say everything, but when you really look at the situation when you need to evacuate, I think the emergency drugs take priority. That is a little bit of a complex situation because not all schools have dedicated school nurses. Those that do not need to think of alternative ways, such as their teachers understanding children's medical histories and needing emergency medication. You also do not know how long the event will last so chronic medical health medications should also be a priority such as asthma or antiseizure medication.

Question 10: What arrangements are/should be made for the use of schools in surge situations?

Answer (Dr. Edward Boyer): What is true of all surge events is how to use any structure, whether temporary or permanent, as a way to decant or offload patient volume into a safe environment. For example, if you had a population that was relatively unaffected, they could be sent to schools. They also could, alternatively, be sent to tents that were set up in parking lots, they could be kept in cafeterias, or other large conference rooms in a medical center. I think the application for it is a way to offload relatively unaffected individuals into a safe environment.

Answer (Bill Modzeleski): One of the issues for schools is, what we have seen is that you cannot do things to schools without notifying the schools of what you are doing. If you put people in schools and do not tell school officials about that, essentially what you are doing is displacing students from the educational environment. This gets back to the whole issue of preparedness being a community response. It is a two-way street. It is the schools working with the community, but it is also the community working with the schools.

Question 11: Does the Commission lean towards family practice as the lead approach to pediatric care outside of DMATs, Disaster Medical Assistance Teams, in disasters with an expectation of compromised patient flows during many incidents (e.g. hurricanes, epidemics, flooding)?

Answer (Christopher Revere): It is a very complex question probably even for some of the more adept on our panel. Right now, the Commission is in a situation where it is gathering information for the subcommittees that have been formed. We do have a Subcommittee on Pediatric Care and I think it is an appropriate question to take back to our pediatric experts. I am not sure if the Commission is going to be making recommendations at that level of granularity, but I do think that Dr. Upperman, who does serve on our Subcommittee, could probably help provide some guidance in this area.

Answer (Dr. Jeffrey Upperman): Dan, I will take a shout out at that one and pay homage to your boss; as we know, he is a family practice doctor, and of course they are a very important part of the medical fabric that would help respond to any crisis. We need all doctors and nurses and other allied health professionals to stand up. I may need a respiratory therapist who in essence would be my working pulmonologist if there is no pulmonologist available and I need as much expertise as they can put on the table to respond. I might need an adult oncologist to become that pediatric oncologist if those pediatric oncologists are not available to help us with trying to do chemotherapy in a parking lot somewhere. I think what we are really talking about is trying to manage during the impossible in a way that makes the most sense with the resources that we have available. It will take flexibility, teamwork, and communication.

Answer (Dr. Edward Boyer): If I could add one other thing, I think it gets back to kind of what I tried to highlight in my talk about how clinicians need to, perhaps, step outside of their normal bounds of practice and adopt some leadership and true responsibility for patient care. Emergency physicians and those in acute medical environments are used to handling things that are not necessarily that comfortable to them, but in an all-hazards situation with lots of patients coming in, triage rules apply, which means that if you are not comfortable with doing something, nonetheless, it is time to step up.

Question 12: Will the Commission's recommendations filter down to States with directed funding for pediatric preparedness?

Answer (Christopher Revere): The Commission is considering several policy recommendations around improving pediatric preparedness at the State and local level. For example, the Emergency Medical Services for Children (EMSC) program is widely regarded as an effective means to support improvement of pediatric preparedness. The Commission shall consider the recommendation of the Institutes of Medicine to fund EMSC at the level of $37.5 million (current funding is $20 million).

Question 13: When there is a lockdown in a school where students go to more than one classroom does anyone have a suggestion for caring for students with such conditions as diabetes other than depending on students to carry emergency supplies?

Answer (Bill Modzeleski): I will start with the 30,000-foot level and then draw it down to the local level, maybe. This is one of the things that I kept on mentioning is that we have 10 percent or 20 percent of our school population that have disabilities of a variety that need medications; peanut butter allergies, autism, etc. All of these things need to be taken into consideration when schools develop their plans; this is why we can't have one plan for the entire school district. This is why every single school district needs to take these things into consideration as they talk about lockdowns and evacuations, and a lot of times kids will have the potential to be evacuated for a long period of time. Is guidance out there? Yes, guidance is out there. Are schools following it? For the most part, we hope they are. It is very difficult, but there is guidance on what to do regarding these students.

Answer (Dr. Sarita Chung): I agree with Bill. This is a very difficult question, and that is why each school should take a look at their particular population. Some suggestions have been made for children to carry their own medications in case they need to be suddenly departed from the building or to be locked in. As Bill said, each school should really look at their population and see what their health/chronic medical needs are and disabilities are to come up with an adequate plan.

Answer (Dr. Jeffrey Upperman): The Pediatric Disaster Resource and Training Center recently collaborated in a disaster response event with the L.A. Unified School District, and it was amazing across all kind of schools with different densities of children with special needs. They all performed very well. The school that had a high density of special needs kids, it was like clockwork, very well organized, and it was clear that the families had plans and were used to dealing with circumstances that were not usual. I think that some of our families may be better prepared than some of our systems, and we should take note and bring them to the table when talking about our system-wide plans.

Question 14: The first part is: Is there an emergency preparedness manual specifically developed for daycare settings? And the second, related question is: Are there other, larger preparedness manuals that include a section in them for either preschools, private, or public daycare settings?

Answer (Bill Modzeleski): Let me start, and then Dr. Chung can pick it up. What we discovered is that there are some very basic principles that need be applied, whether it is a nursery, school, preschool, a K-12 school, or an institution of higher education. These principles can be found in our Emergency Crisis Manual that is posted online. That provides very much some of the same things that Dr. Chung made in her presentation, some of the key principles that every institution, whether it is an institution of higher education or preschool, needs to address. What is not in there are some of the specifics related to very young children.

Answer (Dr. Sarita Chung): I have to agree with Bill and would say that there is no regulation of daycares to have emergency response manuals. Some are mandated by States, but some States do not. I think that, as Bill said, some of the same principles for schools and higher learning apply. For the younger children, you want to try to think about tracking and identification and how you would unify them with their families.